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September 30, 2010

Cocaine As A Medically Approved Medication

Many people are already aware that marijuana is now legal in some states in the US with a medical prescription.

What many people may not realize is that cocaine is also used in medical care, especially in the ENT world.

Cocaine is one of the most potent anesthetic AND vasoconstrictor. These two characteristics make it an ideal medication for use during sinus surgery as well as any nasal procedure where bleeding and pain may be an issue.

Many physicians will use cocaine to help stop nosebleeds (I do not).

Many surgeons use cocaine during sinus surgery to minimize post-operative pain as well as minimize intra-operative bleeding. Use of cocaine also significantly decreases risk of nosebleeds after sinus surgery as well as minimize need for nasal packing.

Cocaine when used for illegal recreational purposes by snorting puts a person at risk for septal perforation due to its vasoconstrictor properties. In essence, the cocaine puts a chemical tourniquet on the blood supply to the septum leading to mucosal necrosis and eventual perforation. Afrin does the same thing, but on a much smaller scale.

Before anybody asks... Cocaine is NEVER prescribed to a patient. It is only ever used in a hospital/office setting and heavily controlled under lock and key. (It is never used in our office.)

Dr. Chang Blog Article Re-Published on KevinMD

One of Dr. Chang's blog article on laryngeal sensory neuropathy as a potential cause of chronic cough has been re-published on KevinMD, an internationally recognized medical blog and contributor to MedPageToday.

The original blog article by Dr. Chang can be read here.

The blog article re-published on KevinMD can be read here.

Pet Dogs Reduce Allergies in Children, But Cats Increase Them

Man's best friend also appears to make us healthy in more ways than one including reducing allergies in children by as much as 4 times according to new research from the University of Cincinnati. On the other hand, cats put children at risk of allergies by 13 TIMES!

The data to obtain these results were obtained from 636 children enrolled in the Cincinnati Childhood Allergy & Air Pollution Study (CCAAPS), a long-term study examining the effects of environmental particulates on childhood respiratory health and allergy development. Notably, all these children are at risk for allergies as their parents have them.

Allergy testing was accomplished by skin prick tests.

Read news article on this here.

Genetic and environmental risk factors for childhood eczema development and allergic sensitization in the CCAAPS cohort. J Invest Dermatol. 2010 Feb;130(2):430-7. Epub 2009 Sep 17

Opposing Effects of Cat and Dog Ownership and Allergic Sensitization on Eczema in an Atopic Birth Cohort. J Pediatr. 2010 Sep 29. [Epub ahead of print]

September 27, 2010

Dr. Chang Mentioned in Newspaper Regarding Spasmodic Dysphonia

The Culpeper Star Exponent released a story on Sept 27, 2010 regarding an individual suffering from ABductor spasmodic dysphonia. This voice disorder is characterized by voice breaks while talking making it very difficult to talk as well as to be understood.

This individual has been treated with botox injections by Dr. Chang who was mentioned in the article:

"Taylor has one of the rarest forms of the disorder and therefore the hardest to treat. Nonetheless, she seeks treatment every four months through Dr. Christopher Chang, an ear, nose and throat specialist based in Warrenton. He is a leading expert in vocal chord treatments, and Taylor is happy he’s located so close by."

Read the story here.

September 25, 2010

Mutter Medical Museum of the Odd, Strange, and Bizarre

In the spirit of Halloween that is coming up soon, I thought to share with everyone a FASCINATING museum located in Philadelphia, PA. The museum's full name is "Mütter Museum of College of Physicians of Philadelphia" and contains a fascinating collection of the bizarre aspect of medical sciences. Many of the exhibits are real and not for the faint of heart.

Of course, I should mention that they have a number of exhibits related to ENT... including one of all the foreign bodies removed from the ear, nose, airway, etc.

Even as a physician who was bored with "The Bodies" exhibit, I am STILL fascinated by what I see in this museum.

Go check it out!

Here are a few images, but more can be found on Google Images.

September 24, 2010

Tilt-Table Test: An Under-Utilized Study To Evaluate Light-Headed Dizziness

We often see patients for dizziness. Many of these patients do not have an ear etiology for their dizziness given principal complaint of light-headedness, especially with standing/sitting up from a laying down position. In this scenario, a blood pressure issue is the more likely cause. Why? Because when you get up from a laying down position, gravity pulls the blood down and away from your head resulting in a transient lack of adequate blood-flow to the brain resulting in light-headedness... and even a fainting spell if severe enough.

Normally, the body is able to compensate for such position changes quickly, but when it doesn't, watch out... Light-headed dizziness or fainting/blacking out will occur.

The best test to evaluate this problem is a tilt-table test. Check out the video to see how this test is performed. Be aware that not all hospitals offer this type of test.

September 23, 2010

Even in Hawaii, People Have Vitamin D Deficiency!

Ever since I've come across reports that Vitamin D supplementation is helpful to decrease allergy symptoms, I've encountered other interesting factoids including this one...

Even in Hawaii where one would expect it's population to get plenty of sunshine, 51% ended up STILL having low vitamin D levels in a study population consisted of 93 adults (30 women and 63 men) with a mean age of 24!!! Read the study here. (For those not in the know, our bodies make vitamin D only with sun exposure.)

How can that be?

Well, given our ancestors probably were out in the sun a lot in terms of farming and/or hunting... our current culture and population does not come even close to the necessary amount of sunshine exposure to maintain adequate Vitamin D levels. After all, many of us work inside buildings instead of outside. We also are applying a lot of suntan lotion preventing the Vitamin D production within our bodies.

Hmmmmmm... Is it possible that the rampant Vitamin D deficiency present in our society is correlated with the increased numbers of allergies/asthma given allergies are worse with low Vitamin D levels?

Low vitamin D status despite abundant sun exposure. J Clin Endocrinol Metab. 2007 Jun;92(6):2130-5. Epub 2007 Apr 10.

Serum vitamin D levels and severe asthma exacerbations in the Childhood Asthma Management Program study. J Allergy Clin Immunol. 2010 Jul;126(1):52-8.e5. Epub 2010 Jun 9.

Vitamin D in atopic dermatitis, asthma and allergic diseases. Immunol Allergy Clin North Am. 2010 Aug;30(3):397-409.

September 22, 2010

New Drug Helps Prevent A Cough From Being Contagious

University of Alberta researchers have developed an experimental new drug that may be able to completely eliminate airborne disease transmission due to cough.

The way this drug works is by reducing/eliminating the amount of droplets that is expelled during a cough by changing the properties of the lung fluid. The drug comes in the form of a spray that can be inhaled by a sick patient.

It is conceived that this drug would help stop the spread of pandemic outbreaks as well as protect healthcare professionals from catching whatever an ill coughing patient may have. Furthermore, this drug would not necessarily be disease specific. If there's a cough, it'll work.

Effect of artificial mucus properties on the characteristics of airborne bioaerosol droplets generated during simulated coughing. Journal of Non-Newtonian Fluid Mechanics, 2010; DOI: 10.1016/j.jnnfm.2010.07.005

September 21, 2010

There are TWO Different Allergy Shot Systems (AAAAI and AAOA)

When it comes to allergy shots, many folks are not aware that there are TWO very different allergy shot protocols available in the United States.

The largest allergy shot system available is by the American Academy of Allergy Asthma and Immunology (AAAAI). The physicians who use this protocol come by way of internal medicine training.

The other allergy shot system (which is the protocol we use in our office) is available by way of the American Academy of Otolaryngic Allergy (AAOA). The physicians who use this protocol (like myself) come by way of Otolaryngology-Head & Neck Surgery (aka, ENT or Ear Nose Throat) training.

Each system uses a different method of how the allergy vials are made. Also, the buildup protocol is different. Just as in baking... there are many ways to bake a cake.

Physicians of one or the other system often pooh-pooh the other, but both systems are based on evidence and are effective.

Where I work in Warrenton, Virginia, our practice (using AAOA) and another (using AAAAI) are the only two practices that provide the full suite of allergy testing and allergy shots. Given both our practices use a different system, I've seen firsthand the benefits of having two different systems available when it comes to allergy shots.

For whatever reason (and this is a personal observation of mine that I can't prove), not all patients respond to allergy shots with one system, but DO respond using the other system. It's not that one system is better than the other... it's just different... and patients benefit from that.

The analogous scenario which I also see involve allergy medications... for some folks, allegra works best whereas for another, allegra does not work at all, but zyrtec works great.

The basic rule of thumb when it comes to allergy shots is that a patient should experience SOME improvement in their allergies after being on shots for at least 1 year. 80% of patients do... For the other 20%, it may be worthwhile to stop and try the other allergy shot system.

September 20, 2010

NPR: Injuries To Kids From Swallowed Disc Batteries Are No Joke... It Is An EMERGENCY!!!

In fact it is a STAT emergency... NPR published a story on Sept 20, 2010 regarding Chuck E. Cheese's recall of two toys (a light-up ring and glasses) due to a disc battery used to power them.

These disc batteries can be access by small children if they smash apart the toy. The Consumer Products Safety Commission says two kids have had problems with batteries; one swallowed it and the other stuck it up his nose.

The danger is that when a disc battery is inserted into a nose (for example), a localized electric current is created between the positive and negative poles of the battery within the nose. This electric current basically "electrocutes" the lining inside the nose leading to tissue damage and ultimately necrosis (tissue death) within an hour. The same applies even if the battery is swallowed or put into the ear canal.

Treatment is IMMEDIATE removal... as soon as possible. Regardless of the day or time. STAT...

In the last 10 years, 13 deaths related to swallowed batteries have been reported, 12 of which are due to disc batteries (20 millimeter lithium cells).

Small children should NEVER be able to access disc batteries.

Read the NPR story here.

Read about the recall itself here (also from NPR).

Preventing Battery Ingestions: An Analysis of 8648 Cases Published online May 24, 2010
PEDIATRICS (doi:10.1542/peds.2009-3038)

A Review of Esophageal Disc Battery Ingestions and a Protocol for Management Arch Otolaryngol Head Neck Surg. 2010;136(9):866-871. doi:10.1001/archoto.2010.146

Images of the toys that have been recalled...

UPDATE: iPad and MediTech Electronic Medical / Health Records

Ever since I wrote my initial impressions of using the iPad with Meditech EMR on June 12, 2010, that blog article has received almost a thousand hits since that time, averaging about 20 hits per day. I've even been featured in Meditech news.

Also in the interval period, I have received numerous inquiries from health systems all over North America using MediTech regarding more specifics on how the iPad is used/incorporated into MediTech EMR.  Due to this interest, I've decided to write an update regarding what is going on since that initial blog article...

SO... I no longer need to use LogMeIn in order to access MediTech. Since then, Fauquier Hospital has upgraded their Citrix infrastructure so I now use a Citrix Receiver app (free in iTunes) to access MediTech.

Things are of course much faster, but still not quite as fast as I would like it to be. Currently, the hospital and I are working to resolve some of the speed issues seen. McKesson PACS (radiology imaging software) also is on the drawing board for direct Citrix access rather than going through MediTech which would also be welcome.

I recently heard from a confidential and utterly reliable source that MediTech has been asked to create a native app for the iPad (thus avoiding Citrix altogether), but the company at this time has politely declined to develop such an app that would hugely improve the user experience and most likely speed.

I would encourage all MediTech users to contact MediTech directly and demand/request that such a native iPad app be developed which would be immensely beneficial and strongly desired. Otherwise, alternative 3rd party software like Citrix will have to be used along with its inherent handicaps.

Click here to view MediTech's contact information.

Related iPad and MediTech Blog Articles:
6/12/10 iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor
6/19/10 The Perfect Computer for Healthcare and Electronic Medical Records
9/8/10 Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR
10/12/10 UPDATE #2: iPad and MediTech Electronic Medical / Health Records
10/25/10 New Video Produced on Using MediTech on the iPad!

September 19, 2010

Using The Internet To Radically Misdiagnose Your Children (Humor)

Saw this from The Onion, published June 2, 2006 (Issue 42; 22)... Though this was meant to be humorous from the folks at The Onion, it does happen unfortunately...

September 18, 2010

As A Busy Physician, Why Do I Even Bother Blogging?

As a busy ENT surgeon in private solo practice (read about me), there are several reasons why I blog (FauquierENT) even though I am already quite busy in my medical practice. As some of my readers have pointed out, it is not unusual to see blogs posted by me at all hours of the night and more commonly, early in the morning on weekends. So what motivates me?

To stay up to date. There are two aspects to this statement. The first is that I am always reading journals and enjoy sharing interesting research/findings that may be of interest to the lay reader. The second is that patients are researching their symptoms on the Internet and bringing the results of their research to their appointment. By being an active blogger, I often read the same stuff patients are and am already familiar with the sources and content even BEFORE they approach me about it. If interesting enough, I myself will write a blog article to either lend further support or to actively dismiss it.

Marketing. The more I write, the more "webpages" there are with my practice affiliation. The more webpages there are, the better the search rankings when people search for information. It is as simple as that. Oh yeah... and it's free unlike yellow pages listing, newspaper ads, etc.

Internet medical reliability. Let's face it. There is a lot of garbage on the Internet when it comes to medical information. By writing what I hope are accurate information on medically interesting subjects (at least on ENT topics) that is understandable AND useful for the lay public, I feel I am doing what small part I can to combat the garbage out there. I've also been very disappointed with information disseminated by reliable sources including WebMD, eMedicine, etc. In these websites, the information is sometimes so nebulous and non-specific to the point of being useless. As such, I try to include information that lay-readers may want to know, specifically details that may be lacking elsewhere.

I like to write. It used to be journal articles and book chapters... But now blogging is so much more gratifying. And to tell the truth, the audience is so much larger than anything achievable through traditional academic publications. It's a nice creative outlet as well.

It is a big time commitment to stay updated. I probably spend several hours a week reading news articles, tweets, blog articles, etc. followed by another few hours writing my own tweets and blog articles. More recently, I've started to make a few ENT videos I've uploaded onto YouTube.
I am not the first, nor the last I hope. Perhaps the most influential medical blogger that has been a role model for me is Dr. Ves Dimov at his CasesBlog site. Check his blog out! Very nice blog with a more general medicine view than my blog. KevinMD is also another popular general medicine blog I follow.

September 17, 2010

Positive Patient Feedback

Dr. Chang received a bonsai tree from Fauquier Hospital for having received positive patient feedback for the past 4 consecutive quarters. How nice!

Read other patient testimonies here.

September 15, 2010

Difference Between In-Network vs Out-of-Network Health Insurance Coverage

To read more about general ideas (copays, deductibles, etc) of how health insurance coverage works, click here.

There are large health insurance companies that offer health insurance plans throughout the United States like Aetna, Anthem, Cigna, etc.

HOWEVER, just because you have one of these companies, does NOT mean that the health insurance benefits that apply in the state you live in apply to the other 49 states in the United States. Sometimes, even within the state, coverage may vary depending on whether the physician you see is IN-NETWORK or OUT-OF-NETWORK with your health insurance plan.

IN-NETWORK coverage means the doctor you see participates fully with your health insurance plan and the copays, deductibles, coinsurances, etc specified on your health insurance card applies.

OUT-OF-NETWORK coverage means that the doctor you see participates with your health insurance plan, but you will have to pay a MUCH larger portion of the bill as your health insurance plan will only cover a much smaller fraction of the charges.

In order to determine whether the doctor you will like to see is in-network or out-of-network, you will have to call your health insurance plan and ask.

Please be aware that your health insurance plan may not even offer out-of-network benefits in which case you are responsible to pay for everything if you see a provider who is not in-network.

A final last point is that some physicians may not even be in-network OR out-of-network with your health insurance plan. In this case, EVEN if you have out-of-network benefits, you will be responsible for all charges out-of-pocket.

To see what insurances we participate with in our office, click here. Just remember that we may be out-of-network, ESPECIALLY if you live in a different state from Virginia.

September 14, 2010

The More Popular You Are, The Earlier You Get Flu (2 Weeks to be Exact)

Actual research was done regarding whether popularity predicts flu trends. Dr Fowler at UCSD and Dr. Christakis at Harvard found that "popular" friends on average get flu 2 weeks before everyone else.

The way this friendship paradox works is as follows: If a person is asked to name a friend, that friend is statistically likely to be more popular than the original individual. Such "popular" individuals typically interact with more people increasing the likelihood of their coming into contact with flu and becoming sick from it earlier than those who are not as popular.

This finding kind of reminds of how miners use a canary bird as an early warning system to see if there are toxic levels of carbon monoxide present before it causes harm to humans.

Read a Reuters story on this research here.

Age Influences Botox Response in Patients with Spasmodic Dysphonia

Dr. Chang recently published a book chapter discussing how age influences response to botox injections in patients suffering from spasmodic dysphonia.

Spasmodic dysphonia is a dystonia (muscle spasms) involving the muscles of the voicebox resulting in involuntary attacks of a strangled sounding voice. Treatment is botox injection to the involved muscles resulting in a decrease of such spasms thereby resulting in a more smooth-sounding voice.

Unfortunately, there are side effects with botox injections to the voicebox including aspiration, dysphagia, breathy voice, etc for a short period of time prior to the good voice. Typically, one week of side effects results in about 3 months of a good voice.

Research into this area typically has been to try and maximize the duration of a good voice while decreasing the duration of side effects.

A prior paper published by Dr. Chang tried to establish what the correct dose is to maximize a good voice and minimize side effects.

This book chapter tries to determine if age influences botox response.

Age and Botox Responses
What was found is a positive correlation between age and duration of normal voice and duration of side effects after botox injection. Age did not appear to play a role in the severity of side effects experienced by patients. However, the number of BTX-A injections received by a given patient was negatively correlated with duration of normal voice and side effects to a degree greater than age.

What does this mean?

Age must be taken into consideration when deciding on what dose of botox to inject since as a patient becomes older, one may see a slow increase in not only duration of normal voice, but also duration of side effects reported. Stated another way, for a given dose, the duration of side effects is larger for an older patient compared with a younger one. However, as the cumulative number of injections a patient receives increases over time, the duration of normal voice and side effects would be expected to decrease slowly.

Age as a Factor in Responses to Botulinum Toxin Injection in Adductor Spasmodic Dysphonia Patients pp. 101-112

Think MRSA Infection is Bad? NDM-1 Infection is Worse!

Image from Wikipedia
NDM-1 (New Delhi metallo-beta-lactamase 1) is an infection for which there is no (or at best maybe only 1 or 2) antibiotic treatment. It is the superman of superbugs.

The NDM-1 actually is a gene that produces an enzyme that deactivates basically all antibiotics and is felt to have originated in India where it was first encountered.

This gene most commonly is found in gram negative organisms like E. Coli and Klebsiella, but the scary thing is that this gene can be transferred from one to another bequeathing its awesome antibiotic resistance. Think superman who can transfer all his powers to a mere mortal easily.

Polymyxins and tigecycline have been found to be the only antibiotics that may have some effect on NDM-1.

Ho-hum superbugs like MRSA (Methicillin Resistant Staph Aureus) can still be eradicated by a few antibiotics like clindamycin and bactrim if community acquired and vancomycin and linezolid if hospital acquired.

I have yet to encounter a patient with NDM-1 and pray that I never do in the future.

Read a news article about a patient who survived NDM-1 as Massachusetts General Hospital (Boston, MA) here.

September 09, 2010

Fauquier ENT Rated #1 in Being Most Influential in Otolaryngology

According to WeFollow, a user powered Twitter directory which ranks profiles based on influence and popularity, Fauquier ENT is rated #1 in influence.

We are not the most popular, however, ranked #3 behind Massachusetts Eye and Ear Infirmary as well as the American Academy of Otolaryngology Head and Neck Surgery.

Check out the rankings here!

Further statistics show that in the area of allergy, Fauquier ENT is ranked #15 in influence and #24 in popularity.

Not bad for a small private practice located in a rural city.

Join us on Twitter, Facebook, YouTube, and of course subscribe to our blog!

Humor: Breast Surgeon vs. Pathologist [video]

There has been a plethora of cartoon animated videos made thru xtranormal regarding how physicians sometimes interact with each other exaggerated to a humorous degree. Here's one regarding a breast surgeon (which can apply to any surgeon including ENT) interacting with a pathologist.

There was an earlier blog post of an orthopedic surgeon vs anesthesiologist here.

New Reason for Chronic Cough... Playing the Trombone!

NPR published a story on Sept 8, 2010 regarding a trombone player whose chronic cough for over 15 years was ultimately found to be due to a mold called fusarium as well as mycobacterium (cousin to TB) found growing inside his trombone. Each time he inhaled while playing the trombone, these germs inside his trombone was causing an allergic reaction, which led to hypersensitivity pneumonitis, a severe inflammation of the lungs.

The doctor who figured out the problem went on to investigate other wind/brass instruments of other players and found them all contaminated with germs. His results have been published in the journal Chest.

Though the NPR story was on this particular trombone player (whose cough improved once he started cleaning his instrument regularly), the problem is NOT new...

Here's a report on a saxophone player.

There is also this one company called MaestroMD that claims to help with musical instrument sterilization.

This issue was so concerning in Massachusetts, that a law is being passed to require sterilization of musical instruments in schools! Read more here.

I even wrote a blog article about this problem back in January 7, 2010.

In any case, how does the trombone player featured in the NPR story now clean his instrument? He uses a rod with a cloth and alcohol — rubbing alcohol or isopropyl alcohol which he pours down into his instrument after playing.

Trombone Player's Lung: A Probable New Cause of Hypersensitivity Pneumonitis. Chest. 2010 Sep;138(3):754-6.

Hypersensitivity Pneumonitis Due to Molds in a Saxophone Player. CHEST September 2010 vol. 138 no. 3 724-726.

A microbiological survey into the presence of clnically significant bacteria in the mouthpieces and internal surfaces of woodwind and brass musical instruments.

Horn with nasty microbes.

September 08, 2010

Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR

On Sept 8, 2010, a story was published in MediTech Magazine regarding how Dr. Chang has piloted the use of the Apple iPad with MediTech electronic medical records used in Fauquier Hospital.

Click here to read the story (pdf document).

Related iPad and MediTech Blog Articles:
6/12/10 iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor
6/19/10 The Perfect Computer for Healthcare and Electronic Medical Records
9/20/10 UPDATE: iPad and MediTech Electronic Medical / Health Records
10/12/10 UPDATE #2: iPad and MediTech Electronic Medical / Health Records
10/25/10 New Video Produced on Using MediTech on the iPad!

Our Office Now Offers Real-Time Video Ear Microscopy

Ever wonder what your ear looks like under the microscope? Ever wonder what it looks like while an ENT is removing earwax from your ear?

Ever wonder what exactly is meant by that "hole" in the eardrum along with any other findings mentioned?

Well, our office now offers real-time video of everything done under the ear microscope.

See exactly what the ENT sees under magnification on a TV screen while he looks into your ear!!!

Or not... but at least you now have that option available!

September 07, 2010

Patients Travel From as Far as 8000 Miles Away to See Dr. Chang

A publication (Healthy Happenings Fall 2010) recently featured Dr. Chang regarding how far some of his patients are willing to travel for treatment.

One patient, Craig Sutherland, comes a few times a year from the Philippines for vocal cord treatment. Another, Margot Hair, travels from Mississippi for vocal cord dysfunction treatment, also a few times a year.

Such long distances that patients are willing to travel to see Dr. Chang is not unusual. At least once a month, there's a new patient who has travelled at least a few hundred miles and a few times a year, from even a different country.

Other locations that patients have travelled from to see Dr. Chang include Canada, Mexico, Italy, and Philippines. Within the United States, patients have come from California, North Carolina, Tennessee, New York, Pennsylvania, West Virginia, etc.

Read the abridged article below (click on it to enlarge). Click here to read the full story.

September 05, 2010

Convert Your iPhone/iPod Into A Hearing Aid With EarTrumpet App!

This fascinating iPhone app called EarTrumpet was developed in collaboration with the Department of Otolaryngology Head and Neck Surgery at University of California Irvine. The app claims to convert your iPhone/iPod into a hearing aid of sorts (hearing enhancer app is the term they use) via headphones with a built-in microphone (the ear buds that come with the iPhone work just fine). In essence, the microphone will pick up the surrounding sound and the app will instantly amplify the sound and play it into the headphones. The degree of amplification is customizable via the app.

Hearing testing is also available.

As per the manufacturer website, the EarTrumpet features include
• use of the built-in microphone on the supplied iPhone ear buds
• allows the user to select which frequencies to boost.
• choose the left or right ear to amplify
• store custom profiles once balance and equalization settings have been selected

You can download the app here which sells for $1.99 (much less than traditional hearing aids which go for $1000 and higher). Watch the tutorial of how the app works below.

On a further note, EarTrumpet was created by Allen Foulad, a medical student.

September 04, 2010

Voice Problems Trouble Teachers

A hoarse voice is an endemic problem in professions who use their voices a lot including preachers, journalists, lawyers, and especially teachers. In the general population, 1 in 4 report a voice problem at some point in their life. Among teachers, 47 percent report some degree of voice abnormality on any given day; 20 percent of teachers report missing work due to voice problems, and 1-in-10 teachers has been forced to leave the profession by voice woes.

Even in Fauquier County, every year there are a few teachers I place on short-term disability due to the severity of their voice disorder.

Read a news article on this subject here.

Voice Problems of Classroom Teachers: Incidence, Symptoms, and Associated Factors (Presented at American Speech-Language-Hearing Association Annual convention, Philadelphia, 2004)

Prevalence of voice disorders in teachers and the general population. J Speech Lang Hear Res. 2004 Apr;47(2):281-93.

September 03, 2010

Dr. Chris Chang... The Ex-Cellist...

I've had plenty of patients ask me about my musical background given my Eastman School of Music Diploma in Cello Performance hanging in my waiting room.

First off... I graduated from the Community Education Division of Eastman School of Music... Not the undergraduate or graduate program. However, it was a very fine education I received there which lasted from 1987-1992 (started playing the cello at age 5 until 24).

In order to receive this diploma (or perhaps a better term would be certificate), I had to complete a specified curriculum including music theory (levels 1-3), composition, music history, piano, chamber music, as well as the dreaded solo performances in Kilbourn Hall and Howard Hanson Hall... not just once, but several times a year.

While attending Eastman, I took private lessons from three awesome teachers including Polly Hunsberger, Ingrid Bock, and David Ying. I was pleased to see my first two teachers still playing with the Rochester Philharmonic Orchestra. Prior to Eastman, I took private lessons at a SUNY Geneseo college with Prof James Kirkwood.

Orchestra-wise, I participated with the Rochester Philharmonic Youth Orchestra, Greater Buffalo Youth Orchestra, and the New York All-State Orchestra. In college, I continued to play the cello with the Yale Symphony Orchestra as well as various chamber groups. I believe I played in my last concert in 1998 after which I pretty much stopped playing.

Some of my favorite cello pieces I played include Cello Concerto No. 1 by Saint-Saens and Cello Concerto in D minor by Lalo. The last cello piece I was working before "retiring" was Cello Concerto No. 1 by Haydn.

My most exciting moment playing the cello is perhaps Overture to Candide by Bernstein with the New York All-State Orchestra.

Another fine moment was Russian Easter Overture by Rimsky-Korsakov with the Greater Buffalo Youth Orchestra.

And yes... the picture posted here is my very own trusty cello... which usually hangs out in my closet, but opened up briefly for the purposes of this blog.

Here's my complete musical CV here.

Will I ever play again??? Well maybe... someday...

Caffeine Can Cause ENT Problems

After reading an interesting article in Forbes that described caffeine as a natural pesticide (for real!), I thought I would pipe in and report the types of problems caffeine can cause in humans from an ENT perpective...

Caffiene can contribute to (some proven, some suspected, some debatable):

• Meniere's Disease
Migraine Headaches
Lump in Throat Sensation (Globus)
Chronic throat clearing
• Dry throat
Phlegmy throat

Alcohol and salt are other big as well as under-recognized items that may cause similar ENT issues.

Bone Drugs May Increase Risk of Throat Cancer

Well, at least that is what USA Today reported on September 3, 2010 with the title "Bone drugs may raise throat cancer risk". In actuality, bone drugs like boniva, fosamax, actonel, etc may possibly increase the risk of esophageal cancer which is actually not "throat cancer" and is in fact treated by a totally different specialty than ENT who is historically considered the throat expert.

Really, the specialty to see regarding esophageal cancer are the gastroenterology doctors or a general surgeon.

In any case, the study published in JAMA found that when taking bone drugs, the risk of developing esophageal cancer (not throat) was 2 in 1,000. Normally, the risk of developing cancer of the esophagus in people aged 60 to 79 is 1 in 1,000.

The increase is not that staggering. Not even close. I call it a "blip" of an increase.

Read the USA Today story here.

Read the JAMA research abstract here.

NPR on Muscle Tension Dysphonia aka (Hyper-)Functional Dysphonia

NPR reported on July 12, 2010 one woman's travail overcoming a raspy voice due to laryngeal hyperfunction (also known as muscle tension dysphonia). Voice therapy provided a cure for her condition.

I should state that muscle tension dysphonia (MTD) is NOT the same as spasmodic dysphonia and the two disorders are often confused with each other... and treated completely differently from each other.

MTD is when the muscles of the voicebox are too tight causing a raspy voice. This very commonly occurs after a viral laryngitis/cold. My (unsupported) hypothesis is that the brain tries to achieve a normal sounding voice in a setting of laryngitis where the voicebox is inflamed and swollen. This attempt at normalcy usually results in hyperfunction of the muscles composing the voicebox.

Unfortunately, once the laryngitis resolves, the patient is still locked into a mode of hyperfunctional voice use, even though there's no more need to do so. In essence, it has become muscle memory or a bad habit.

Voice therapy in its purest form tries to get the brain to revert back to a more normal muscle pattern while talking by essentially teaching the patient to break this bad habit. Whether that includes laryngeal massage as in the article or via specific vocal exercises, it depends on the patient. There is not one specific treatment that will work on everyone with this condition.

Spasmodic dysphonia is when specific muscles of the voicebox goes into spasm, much like people with eye twitches. It is involuntary and occurs at random without warning. Treatment for spasmodic dysphonia is botox injections. Voice therapy does play a limited role in allowing for a longer duration of botox effectiveness which typically wears off in about 3 months before repeat injection is required.

Read the NPR story here.

Read more about muscle tension dysphonia here.

Read more about spasmodic dysphonia here.

Of note, our clinic specializes in these disorders.

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